Controversies about tissue plasminogen activator: extending the window of therapy.

The management of stroke has undergone significant development over the past 15 years. Perhaps the single most important landmark has been the approval by the Food and Drug Administration of intravenous (IV) tissue plasminogen activator (t-PA) for the treatment of ischemic stroke. However, the approval of this drug has not met with unanimous support by the medical community and, at present, only a minority of stroke patients receive t-PA. Although this is partly due to the fact that many patients do not meet criteria for treatment with IV t-PA, others simply do not arrive at medical facilities sufficiently early to be safely managed using thrombolysis. The appropriate use of IV t-PA in the treatment of ischemic stroke requires proper selection of patients and strict adherence to clinical protocols of treatment. The ideal stroke patient for treatment with IV t-PA is one who suffers occlusion of a small artery that leads to a disabling deficit.